Transcript Neurological Management KSU

Pathology
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The pathology involving the CNS arises from
injuries, vascular insufficiency, tumors,
infections and disorders from other diseases.
Neurological medical problems are due to
interference with normal functioning of the
affected cells
Nervous System
Anatomy and Physiology
Review
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The nervous system acts as a coordinated
unit both structurally and functionally
Communication network responsible for
coordinating and organizing the functions of
all body parts
The body’s link to the environment
Works with the endocrine system to maintain
homeostasis
Reacts in a split second
Functions
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1.Regulates system
2. Controls communication
3. Coordinates Activities of body system
Divisions
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Central nervous system ( CNS) : brain and
spinal cord –interprets incoming sensory
information and sends out instruction based on
past experiences
Peripheral nervous system ( PNS) : Cranial
and spinal nerves extending out from brain and
spinal cord---carry impulses to and from brain
and spinal cord
Neurological Terms
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Anesthesia- complete loss of sensation
Aphasia-loss of ability to use language
Auditory/receptive aphasia- loss of ability to
understand
Expressive aphasia- loss of ability to use spoken or
written word
Ataxia- uncoordinated movements
Coma- state of profound unconsciousness
Convulsion- involuntary contractions and relaxation of
muscles
Neurological terms
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Delirium- mental state characterized by
restlessness and disorientation
Diplopia- double vision
Dyskeinesia- difficulty in voluntary movement
Flaccidd- without tone- limp
Neuralgia- intermittent, intense pain, along the
course of a nerve
Neurological terms
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Neuritis- inflammation of a nerve or nerves
Nystagmus- involuntary, rapid movements of
the eyeball
Paresthesia- abnormal sensation without
obvious cause, with numbness and tingling
Stupor- state of impaired consciousness with
brief response only to vigorous and repeated
stimulation
Vertigo- dizziness
Preparing a patient for a diagnostic
test
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Answer question that the
patient may need clarification
Diet orders –NPO???
Special room or equipment
used
Special medications required
for test
An informed patient will be
more cooperative
Nursing assessment
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Baseline vital signs and neuro
cks
Know level education to
develop an individualized
teaching plan
Determine awareness of
actual or potential medical
diagnosis
Determine previous
experence with Dx test
Diagnostic test/ methods
A. Computerized Tomography- CT or CAT scan
computer analysis of tissues as x-rays pass
through them; has replaced many of the usual
tests: no special preparation or care after test
CT scan
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Nursing Interventions
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Explain procedure – will be enclosed tunel
Written consent
Assess allergies to iodine
Remove wigs hair pins or clips, partial denture plates
Assess for pacemakers
NPO 4 hours before if oral contrast is administered
Encourage patient to drink fluids to avoid renal complications
and to promote excretion of the dye
Diagnostic test/ methods
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B. lumbar puncture- spinal tap
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Done under local anesthesia a puncture is made at
the junction of the third and fourth lumbar vertebrae
to obtain a specimen of cerebrospinal fluid (CSF)
CSF pressure measured
Used to inject medications- spinal anesthesia
Used to inject diagnostic materials –air or dyemyelogram
Lumbar puncture
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Nursing interventions
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Written consent
Monitor vital signs
Have patient empty bowel and bladder
Position the patient
Label and number specimens
Keep patient supine 4-8 hours
Observe for headache and nuchal rigidity
Observe for mobility of extremities, pain, ability to void
Monitor site for leakage
Diagnostic test/ methods
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Cerebral Angiography- intraarterial injection of
radiopaque dye to obtain an xray film of the
cerebrovascular circulation
Cerebral angiography
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Nursing interventions
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Written consent
Assess for allergy to iodine
NPO past midnight
Administer preprocedure medications
Observe arterial puncture site
Monitor extremity for adequate circulation- pain tenderness
bleeding temperature and color
Pedal pulses and vital signs q 1 hour
Provide ice pack to puncture site
Bedrest 12- 24 hours
Force fluids- to increase excretion of dye
Diagnostic test/ methods
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Electroencephalography (EEG)- electrodes are
placed on unshaven scalp with tiny needles
and electrode jelly
EEG
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Nursing Inventions
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Anticipate patient’s fears about electrocutions
Explain procedure
Written consent
Hair should be clean
Do not give stimulants/ depressants before test /consult with
M.D. about meds
Administer sedatives or hypnotics if ordered
No smoking or caffeinated beverages before the test
Eat full meal before the test –hypoglycemia may alter brain
waves
Stress need for restful sleep before the test sleep deprivation
may cause abnormal brain waves
Wash hair and scalp after test
Diagnostic test/ methods
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Brain Scan-after injection of a radioisotope,
abnormal brain tissue will absorb more rapidly
than normal tissue: this can be detected with a
Geiger counter to diagnose brain tumors
Brain Scan
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Nursing interventions
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NPO 4 hours before test
Remove wigs, hair clips or pins,
Assess for iodine allergies
If ordered give sedation
Encourage fluids after test to increase excretion of
dye
Diagnostic test/ methods
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Magnetic Resonance Imaging- ( MRI)
uses combination of radio waves and a strong
magnetic field to view soft tissue ( does Not
use x-rays or dyes) ; produces a computerized
picture that depicts soft tissues in high –
contrast color
MRI
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Nursing interventions
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Written consent
Explain procedure- will have to remain perfectly still
in the narrow cylinder-shaped machine . No pain or
discomfort but no room for movement
Assess for any metal contraindications-pacemaker,
surgical clips, hair clips, belts
Empty bladder before test
Diagnostic test/ methods
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Myelogram- injection of a radiopaque dye into the
subarachnoidd space via a lumbar puncture:
performed to locate lesions of the spinal column or
ruptured vertebral disk
Myleogram
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Nursing interventions
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Written consent
Prepare for LP
NPO for 4 hours before test
Positioning for LP
Vital signs
Observe for photophobia, fever stiff neck, occipital headaches,
nausea , dizziness, and possibly seizures
Force fluids to promote dye excretion dehydration will result in
severe headache
Check with M.D. when withheld medications prior to test may
be restarted
Observe site for leakage of CSF
Bedrest
Nursing Diagnosis and
Interventions
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Identify the patients needs
Neuro checks
Assessment of history from family
Patient history
Nursing observations
Impaired Physical Mobility
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Neuro checks q2-4h
Explain the need for regular
exercise program
ROM to all joints q2-4h
foundations pg 243-244
Use assistive devices
Protect the affect side from
injury
Protection from falling
Turn q2h
Risk for injury/infection related to
fixed eyes ( no blinking)
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Protect with eye shields
Remove dry exudate
with warm saline
Close eyes
Inspect for inflammation
Ineffective breathing pattern related
to neuromuscular impairment
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Maintain patent airway
Suction as needed
Elevate HOB 30-60degrees
Have trach set ready
Provide O2 with humidity
V/S with neuro cks q2h
Oral hygiene q2h
Lubricate lips
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Maintain bed rest
Keep unconscious pt in
lateral position to allow
secretion drainage
Monitor for S/S
pulmonary emboli
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Chest pain, SOB,
Monitor ability to swallow
Risk for alteration in body
temperature
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Asses rectal temp q2h
Use external heating or
cooling blankets
Risk for aspiration
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Maintain NPO
Position Pt on side: turn
q2h
Provide N/G feedings
Monitor IV fluid
Altered patterns of urinary
elimination
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1. Oligura-urinary
retention
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Provide indwelling
catheter
Monitor I&O qh
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2. Incontinence
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Wash dry and inspect
skin
Implement measures to
prevent decubitus ulcers
Implement bladder
training
Bowel incontinence/constipation
Incontinence
wash dry and inspect
skin
Implement measures to
prevent decubitus ulcers
Implement bowel training
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Constipation
-Record bowel movements
-Provide stool softners,
laxatives and enemas
-Check for impaction
-Increase fluid intake
-Increase Fiber in diet
-Increase activity
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Altered Nutrition: less than body
requirements related to dysphagia
and fatigue
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Prepare for N/G
feedings
Check gag reflex
Provide mouth care,
clean and care for
dentures
Place food in patients
visual field do patient
can see food
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Diet low salt low
cholesterol
consult dietary
Wt daily
Impaired Communication
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Assess communication
patterns
Provide calm environment
with minimal distraction
Use touch to increase
attention
Use familiar music to
enhance recall
Simple verbal commands
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Communication boards
Pen and paper
Gestures eye blinks
Fluid Volume deficit
Inability to meet needs:Coma
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COMA-Unconscious state in which the Pt is
unresponsive to verbal or painful stimuli: this
occurs with many primary diseases: the Pt
depends on the nurse for maintenance of all
basic human needs, nourishment, bathing,
elimination, respiration, prevention of
complications and assessment and provision of
care for problems
Coma : nursing interventions
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Include family in nursing care and planning
Note LOC q15 minutes
Nero Ck q 15 minutes
Demonstrate respect for Pt presence
Provide quite restful environment
Speak to Pt, use proper name, introduce self,
explain all care
Provide privacy
Patient with paralysis
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Paraplegia-paralysis of the lower extremities
There may be no motion or sensory function or reflexes
There may be uncontrollable muscle spasms
Perspiration ceases then becomes profuse
Loss of bowel and bladder control
Anxiety, fear, depression, anger, and embarrassment
May be totally dependant
Patient with paralysis
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Quadriplegia- paralysis of all four extremities
Same problems as paraplegia
Nursing interventions : Paralysis
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Take measures to prevent complications of immobility
Bowel and bladder training
Prevent deformity: maintain joint mobility: correct
alignment
Increase fluid intake
Provide high protein diet
Teach independence according to ability
Work with health care team for rehabilitation
Include family in planning and care
Increased intracranial pressure
( ICP)
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Fluid accumulation or a lesion takes up space
in the cranial cavity, producing ICP: the brain is
gradually compressed, or life-sustaining
functions cease: may be sudden or progress
slowly
ICP
Causes
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Tumors
Hematoma
Edema from trauma
Abscesses from infection
ICP
signs and symptoms
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Headache, restless, anxiety
Vomiting,recurrent, projectile,
and not related to nausea or
meds
Change in pupil response to
light
Seizures
Respiratory difficulty;
irregular, Cheyne-Stokes or
Kussmaul
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BP elevates ,with wide pulse
pressure
Pulse Increases at first then
slows to 40- 60
Alter LOC,lethargic, speech
slows, confused, decrease
level of response
Visual disturbances,diplopia
and blurred vision
Progressive weakness or
paralysis
Loss of consciousness,coma
death
ICP
Treatment
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Depends on cause
Craniotomy
Meds
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Steroids
Anticonvulsants
Mannitol
dexamethasone
ICP
Nursing interventions
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Elevate HOB to semi-Fowler’s
Never place in Trendelenburg
V/S and neuro cks q15 minutes
Prevent aspiration
Place Pt on Side
Maintain airway- O2
Observe pupillary response ( usually unequal and may
not react to light)
Report changes in LOC immediately
Seizure precations
Provide care for Coma Pt
Convulsive disorders
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Frequently a convulsion or seizure is not a
disease but a symptom of a neurologic
disorder:
Epilepsy is a disease characterized by a
disposition for seizures;
Types of seizures
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Generalized or grand mal
Aura- There may be a premonition or sign
The Pt cries out
Loss of consciousness
Enters tonic phase- the body is rigid and the jaw is
clenched
Then the clonic phase- jerking movements of
muscles
Cessation of respiration
Fecal and urinary incontinence
Lasts 1-2 minutes
Types of seizures
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Partial or petit Mal
Loss of consciousness that last 5- 30
seconds
Normal activities may or may not ceas
There may be amnesia concerning the time
Types of seizures
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Jacksonian or Motor
A focal seizure that may precede a grand mal
seizure
Convulsive Disorders
Causes
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May be secondary to another condition
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CVA, head injury, brain tumor, elevated temp, toxins,
electrolyte imbalance
Epilepsy may have no known cause
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Onset is usually during childhood or before age 30
Convulsive Disorders
Diagnostic test
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EEG
CT scan
MRI
Convulsive Disorders
Treatment
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Treat and remove cause
Anticonvulsant drugs
Surgery – sterotactic- electrical stimulation to
locate and reset ( destroy) epileptogenic focus
Convulsive Disorders
Nursing Interventions
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Provide accurate observation and documentation
Aura
Time of onset
Whether seizure is generalized or focal
Specific parts of body involved
Progression of seizure
Eye movements
Loss of consciousness
Loss of bowel or bladder
Condition after seizure
Memory loss
Convulsive Disorders
Nursing interventions
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Encourage Pt to wear medical alert tag
Have suction available
During seizure maintain airway
Prevent head injury
Place pt on side
Protect extremities from injury
Do not restrain
Loosen clothing
Remove pillows
Maintain safety until fully conscious
Transient Ischemic Attacks
TIA
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Altered cerebral tissue perfusion related to a
temporary neurologic disturbance
Manifested by sudden loss of motor or sensory
function
Lasts for a few minutes to a few hours
Caused by temporarily diminished blood supply
to an area of the brain
High risk for stroke
TIA
Treatment
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Control hypertension
Low sodium diet
Possible anticoagulant therapy
Stop smoking
Cerebrovascular Accident
CVA
Stroke
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Decreased blood supply to a part of the brain
caused by rupture , occlusion, or stenosis of the blood
vessels
Onset may be sudden or gradual
Symptoms and patient problems depend on location
and size of area of brain with reduced or absent blood
supply
right CVA results in Left side involvement often
associated with safety/ judgment
Left CVA results in Right side involvement often
associated with speech problems
Cerebrovascular Accident
CVA
Stroke
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Symptoms related to location and size of brain area
affected
Approximately 50% of survivors permanently disabled
High proportion experiencing recurrence within weeks
to years
Chances for complete recovery depending an
circulation returning to normal soon after the initial
stroke
Third most common cause of neurological disability
Predisposing factors-CVA
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History TIA’s
Hypertension
Arrhythmias
Atherosclerosis
Rheumatic Heart
Disease
MI
DM
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High serum triglyceride
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Lack of exercise
Cigarette smoking
Family history
CVA
Causes
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Incidence increased with aging
Atherosclerosis
Embolism
Thrombosis
Hemorrhage from ruptured cerebral aneurysm
hypertension
CVA
Signs and Symptoms
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Altered LOC
Change in mental status
Decreased attention span
Decreased ability to think and reason
Difficulty following simple directions
Communication; motor and sensory aphasia difficulty
with reading ,writing, speaking, or understanding
Bowel and bladder dysfunction retention impaction or
incontinence
CVA
Signs and Symptoms
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Seizures
Limited motor function; paralysis, dysphgia, weakness ,
hemiplegia, loss of function
Loss of sensation/ perception
Headaches and syncope
Loss of temp regulation elevated TPR and BP
Absent of gag reflex ( aspiration)
Unusual emotional responses; depression, anxiety,
anger, verbal outburst, and crying: emotional lability
Problems related with immobility
CVA
Diagnostic test
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Physical assessment
Pt and family history
EEG
CT scan
Lunbar puncture
Cerebral angiogram
Carotid ultrasonogram
CVA
Treatments
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Remove cause, prevent complications, and maintain
function, rehabilitation to restore function
Meds
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Antihypertensives
Anticoagulants
Stool softners
Surgical removal of clot, repair of aneurysm, carotid
endarterectomy or balloon agioplasty
CVA
Nursing Interventions
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Patent airway
Maintain bedrest
Provide complete care
Use turn sheet
Footboard
Firm mattress
Pillow and torchanter rolls
Maintain proper body
alignment
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Place items within reach
Reposition q2h
ROM passive and active
Place in chair
Flotation mattress or
sheepskin
Skin assessment
CVA
Nursing Interventions
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O2 with humidity
C,T, DB q2h
Suction PRN
Keep head turned to
side
Place in semi- fowler’s
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Assess nutrition daily with
I&O, WT, %diet, calorie count
Provide N/G feedings if
needed
Maintain IV fluids
Progress to soft diet prn
TPN as ordered
Aspiration precautions
Dietary consult & Speech for
swallowing
CVA
Nursing interventions
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Establish means of
communication
Nonverbal gestures
Speak slowly
Explain all care
Speech therapy
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Encourage family
participation
CVA
Nursing Interventions
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Assess LOC
Maintain safety
Use side rails
Restrain only as
necessary
Observe for ICP
V/S & Neuro CKS q 4 h
Seizure precations
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Ensure elimination
Assess bowel sounds
Monitor bowel
movements
I&O
Indwelling catheter prn
Bowel and bladder
training
CVA
Nursing interventions
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Family support
Begin discharge
teaching early
Physical therapy
Speech therapy
Brain Tumor
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A benign or malignant growth that grows a nd
exerts pressure on vital centers of the brain
decreasing function and causing increased
intracranial pressure
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Cause is unknown
Brain Tumor
Signs and Symptoms
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Personality changes, fear and anxiety
H/A , dizziness and visual disturbances
Seizures
Pituitary dysfunction
ICP
Local paralysis or anesthia
Aphsia
Problems with coordination
Brain tumor
Diagnostic test
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History
Physical exam
Neurologic assessment
EEG
CT
Angiogram
MRI
Brain tumor
treatment
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Surgical removal –craniotomy
Combination of radiation or chemotherapy
Brain tumor
nursing interventions
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Neuro cks q 1-4 hours
depending on pt status
Safety
Seizure precautions
express fears and
feelings
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POST OP care
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Maintain airway
Seizure precautions
Regulate body temp
Position on unoperated side
Elevate HOB ONLY under
MD orders
Inspect dressing q30min
V/S neuro cks q 15 min
progress to q4h
Coma care
Head injuries
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Trauma to scalp, skull, or brain. A fracture to
skull may result either a simple break in the
bone or bone fragmentation that penetrates the
brain tissue, can also cause hemorrhage,
concussion, or contusion
Head injuries
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Cerebral concussion- injury to the head, patient
may be dazed; or unconscious for a few
minutes: some function(memory) may be
impaired for as long as several weeks
Cerebral contusion- head injury causing
bruising of brain tissue> person experiences
stupor, confusion or loss of consciousness: if
severe may go into coma
Head injuries
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Cerebral laceration- a break in continuity of
brain tissue
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Causes
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Blow to head
MVA
Fall
Head injuries
Signs and Symptoms and
diagnostic test
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Nausea & vomiting
Lethargic: increasing
loss of consciousness to
impending coma
Disorientation
Drainage of CSF from
ear or nose
ICP
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History and physical
exam
X-ray of head
Angiogram, doppler
studies
CT head, MRI
PET
Head injuries
Treatment
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Anticonvulsulants
Corticosteriods
Mannitol
Maintain fluid balance
surgery
Head injuries
Nursing interventions
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Care for ICP
COMA care
Neuro cks & V/S q 15
min to q1h
Maintain airway
Seizure precations
Observe ears and nose
for CSF
Multiple Sclerosis
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A chronic progressive disease of the brainand
spinal cord: lesions cause degeneration of the
myelin sheath and interfere with conduction of
motor nerve impulses: there are periods of
remissions and exacerbations: onset occures
in young adult: it has an unpredictable
progression
Cause: unknown< exacerbates with stress
Multiple Sclerosis
Signs ands symptoms
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Ataxia
Paresthesia
Weakness and loss of
muscle tone
Loss of sense of position
Vertigo
Blurred vision –progress
to blindness
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Inappropriate emotions
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Euphoria, apathy,
depression
Dysphagia
Slurred speech
Bowel and bladder
dysfunction
Sexual dysfunction
spasticity
Multiple Sclerosis
Diagnostic test and treatments
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History Physical exam
Neuro Cks
Ct
MRI
Exam of CSF
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Treatment is
symptomatic
Corticosteriods during
acute excerbation
Multiple Sclerosis
Nursing interventions
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Prevent Complications of
immobility
Encourage independence
Patient should participate in
plan of care
High calorie, vitamin, protein
diet
Family education
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Bowel and bladder training
Safety
Express feelings regarding
dependence and disabilities
Avoid precipitating factors for
exacerbations
Fatigue, cold, heat, infections,
stress
Parkinson’s Disease
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A progressive , degenerative disease causing
destruction of nerve cells in the basal ganglia of the
brain caused by a deficiency of dopamine: limbs
become rigid, fingers have characteristic pill rolling
movement, and head has to and for movement: the
patient has a bent position and walks in short, shuffling
steps: facial expressions become blank with wide open
eyes and infrequent blinking ( parkinson’s Mask)
Intelligence is NOT affected
Parkinson’s Disease
Signs and symptoms
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Tremor
Voluntary movement is slow
and difficult
Coordination is poor- ataxia
Impaired chewing and eating
Excessive salivation and
drooling
Speech is slow
Patient is soft spoken
Written communication is
difficult


Excessive sweating
Emotional changes
–
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Depression , confusion
dependency
Parkinson’s Disease
Dx test and treatments
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History
Physical exam
Neuro cks
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Many pt s respond to
drug therapy and the
disease is controlled with
meds for the reminder of
their lives
Others have no
response to meds invalidism
Parkinson’s Disease
nursing interventions


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Foster independence
ADL’s
Avoid social withdrawal
–involve in work, social
and diversional activities
Aviod embarrassment
while eating
–
Use straws, wipe drool,
use bib, keep clothing
clesn, use large handle
grips
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Soft diet
Daily walking—safety
Avoid fatigue
Physical, Speech and
Occupational therapy
Avoid constipation-stool
softner
Parkinson’s Disease
nursing interventions

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Bowel and bladder
training
Be patient when patient
is slow and clumsy
Establish a means of
communication
Reorientation
Prevent pneumonia


Mouth care q4h
Family participation
Spinal Cord Impairment

The vertebral column houses the spinal cord.
A small cartilage disk acts as a cushion
between the vertebrae. All sensory and motor
nerves to the neck, trunk, and extremities
branch out from the spinal cord. The degree of
disability and patient problems is related the
part of the body controlled by the injured or
disease nerves
Spinal Cord Injuries



Trauma to spinal cord may cause complete or
partial severing of the spinal cord
If severing is complete there is permanent
paralysis of body parts below site of injury
When there is partial damage edema may
cause a temporary paralysis
Spinal Cord Injuries
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Cause : accident ,MVA diving, shooting
S&S individual to site, respiratiory distress,
paralysis
DX test: physical exam
Treatment: immobilization
–
–
Crutchfield tongs.halo traction.brace.body cast
Surgery corticosteroids, mannitol
Spinal Cord Injuries
Nursing interventions

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Care for paralysis patient
Observe for complications of spinal shock
Maintain airway and respiratory function